Since 1989 we have been using custom lateral-flare stems. Using this stem, its lateral flare can produce high proximal fit and less fit in distal part. Applying this automatic designing software to the average femoral geometries, we can make off the shelf high proximal fit stem (Revelation ®). Putting the off the shelf stem, the original center of the femoral heads were well reproduced. But in DDH cases, severe deformities around hip sometimes make complicated difficulty for better functional reconstruction. They are high hip center such as Crowe II-IV, shortening of the femoral neck, high anteversion etc. DDH cases are well known to have higher anteversion than non DDH cases. There would be no definite explanations for it. The high anteversion would not always be harmful for the preoperative patients. But in some cases, osteophytes are observed at posterior side of the femoral head which make another sphere with different centre. We can guess that the patient's biomechanics had not been matched with the original anteversion. Then posterior osteophytes can correct inappropriate anteversion (self-reduction.) (Fig.1) In those patients, reduction of the anteversion by putting stems twisted into the canal or using modular stems are sometimes done by the surgeons' decision. Younger DDH cases can also be treated with THA, because of the complicated deformities or biomechanical disorders. Short stems are expected to reduce operative invasion and stress shielding then can reserve bone quality and quantity. From these point of view to improve the understanding of the characteristics of the DDH anteversion, and design a DDH oriented short stem could be one of good solution for those cases.
For the better understanding of the high anteversion 57 femora (mean anteversion: 34.4 deg.) were analyzed slice by slice. The direction of femoral head centre, lesser trochanter (LTR), linea aspera (aspera) just below LTR, aspera in the middle of the femur and aspera between the last 2 sections. All of the directions were assessed from PC line To clarify the meaning of the head osteophytes, 35 operated cases were analyzed the extent of the head osteophytes. According to the results, a DDH oriented short stem was designed.Introduction
Method
Since 1989, we have been developing lateral flare stem. The concept of lateral flare stem is to deliver proximal part big enough to fill the proximal cavity that most of the cement stems can fill and most of the cementless stems cannot. Also having distal part polished, much less distal load transfer occurs than cement stem. Thus, we can expect high proximal load transfer to prevent stress shielding. To deliver lateral flare stem, straight insertion path cannot be available, as proximal lateral part to fill inside the greater throchanter collides to the greater trochanter. So 3-Dimension insertion path was calculated to deliver that part through the narrow made by neck osteotomy. The first generation of the lateral flare stem was custom made. The second generation was designed as an off-the-shelf stem from what we have learned by the experience of custom stems. With the third generation, the stem was shortened to achieve more proximal load transfer. Direct Anterior Approach (DAA) developed by Judet is one of less invasive hip approach. With a stem with straight insertion path, the extended line of proximal femoral axis should come out of the skin. To achieve this position, proximal end of the femur has to be fully pulled up. (Fig.1) Some of the cases would be able to be lifted up but some have difficulty. Using lateral flare stem with curved 3 dimensional insertion path, even the axis extension does not come out of the skin, it would be expected to be inserted. In the present study, 3D insertion path of the lateral flare short stem for DAA was analyzed. Preoperative CAT scan data were transferred to STL data by Mimics®. The procedures after that were done by Magics®. First, neck osteotomy was done, externally rotated, and mild extension that doesn't make the axis come out of the skin was added. Then insertion path was verified keeping the stem attached medial sidewall of the canal (Fig. 2). In actual case, skin translation and pelvis rotation was assessed by 3D scanner. (Fig. 3)Introduction
Materials and methods
During THA in lateral position, keeping accurate lateral position is very important for obtaining good cup position. We normally use two kinds of hip positioner, but sometimes we can only use universal positioner provided with operational table. The pelvic tilt can be changed by surgical procedures such as traction, dislocation, reduction and so forth. In the present study, pre-op and post-op pelvic tilt was assessed using Kinect (Xbox 360′s sensor) as 3D scanner. As a 3D scanner, “Kinect®” was used (Fig. 1) with scanning software “Artec Studio 9 ®”. First, accuracy of the scanning system was validated, then 6 postero-lateral approach hip replacement with lateral position surgery cases (Fig.2) (1 male and 5 female, average 55.5 y.o., average BMI 27.6, IMP® positioner: 3 cases, Kyocera positioner: 2 cases, universal fixator provided with surgical table: 1 case), one direct anterior approach case, and one supine antero lateral case (Fig. 3) were scanned pre and post operatively. Pelvic tilts were assessed using tableside rails or edges of positioner that is tightly fixed to the table, as the reference.Introduction
Materials and Methods
Biomechanists have been trying to obtain integrated and accurate human motion data. However, it is not so easy, because some have limitation of accuracy, some have limitation of the observation area, and some are expensive. For example, motion capturing can obtain whole body motion data, but needs space, is expensive, but only surface motion could be obtained. So is not so sensitive for the bone rotation. Sensors of pressure, acceleration, and so forth are less expensive and less hard to use, but the data are limited. 2D–3D shape matching such as Jointtrack can describe bone motion including rotation, but the detectable area is limited by the size of flat panel fluoroscopy. In this study, we have combined multiple joint motion analysis by Jointtrack and reconstructed full lower extremities' motion. Pelvis, bilateral femurs, and bilateral tibiae geometries were obtained from CAT scan using Mimics®. Gait motion fluoroscopy was done on a treadmill around hip joints and knee joints (Fig.1). On each heal thin film switch was attached and connected to electrically driven metal flag which can be recorded in fluoroscopic images on heal strikes. Images of five gait cycles were taken with 15Hz and every image was sorted by the percentage of gait cycle, and then processed by Jointtrack. Centre of femoral head of observing side was defined as our origin. Using treadmill, the walking direction could be uniquely defined. From the femoral 3D displacement and rotation, knee position can be calculated. The same procedures were done for the knee assessment, mutual coordinate of hip centre from the knee can be calculated. All of them are sorted by the percentage of the gait cycle too. Combining data from hip and knee, complete lower extremities' motion could be described. Regression analyses of x, y, z coordinates of femurs from hip and from knee were done to evaluate the accuracy. Motion capture of floor gait and treadmill gait were done to evaluate the difference. (Fig.2)Introduction
Method
In THA of DDH cases, sometimes shortening and/or derotational subtrochanteric osteotomy is required, for cases with high hip center and/or high anteversion. Initial fixation is one of the most important problems after subtrochanteric osteotomy. To prevent rotational displacement V-osteotomy or step osteotomy is often used. Even though until the osteotomy part unites, additional fixation is required. When a stem with distal load transfer was used body weight can be transferred to healthy part, so early full weight bearing should be expected. However, the muscles around hip joint can pull up proximal part, so it would be possible osteotomy part to be split. When a stem with proximal load transfer, body weight would be loaded on non united osteotomy part. So full weight bearing could sometimes be postponed. A stem that has both proximal and distal load transfer, and has facility for prevent rotation, those situations would possibly be simply solved. Lima (Italy) has a proximal load transfer conical stem with fins “Modulus” and a distal load transfer conical stem “Revision.” Combining these two stems, a stem as explained prior was designed. In the present study, applicability of the stem for cases such as subtrochanteric osteotomy was assessed. The stem geometry data were provided by the maker. Forty CAT scan DICOM data, 12 male, 28 female, 58+/−13.8 Y.O. were transferred to STL geometry data using Mimics®. Then using Magics® fit studies were done. For each femur, most suitable size of conventional “Modulus” and double conical stem “Modulus R” were selected to have tight fit making greater trochanter top height as head center height, then the area where stem core attaches to the inside surface of the canal were determined.Introduction
Materials and Methods
For hip prostheses, short stems allow easy insertion and reduce thigh pain risk, and are therefore suitable for Minimally Invasive Surgery. However, clinical outcome depends on sufficient initial fixation in the proximal femoral component. Revelation stems are designed to increase medullary cavity occupancy in the proximal femoral component and allow physiological load transmission within this component. Theoretically, on initial fixation of the proximal part of the stem, fixation remains unaffected by cutting the distal part of the stem. Recently, the Revelation micro MAX stem has become available. In this system, only the distal part of the stem is removed. To prepare for the introduction of this stem, we evaluated its rotational stability by installing it in the femurs of formalin-fixed cadavers. We then evaluated the time course of changes in bone density at the stem circumference and stem position by CT in the first eight patients undergoing hip arthroplasty. Micro MAX stems were inserted into the left femurs of one male and six female cadavers (76 to 95 years of age). A commonly used torque meter was mounted on the stem, and stem fixation was evaluated by the application of clockwise torque of 6 to 12 N-m. Further, in patients, three men and five women (age range 38–83 years, mean 67 years; two cases of femoral head necrosis, two of femoral neck fracture, and four of osteoarthritis of the hip) who underwent surgery with the micro MAX stem from July 2012 to April 2013 were evaluated at 3 weeks, and 3 and 6 months after surgery for stem insertion angle and stem subsidence by CT, and for bone density around the stem by the DEXE method.Background:
Subjects and Methods:
Obesity is one of the biggest issues to harm health so as increase medical costs worldwide. Unfortunately, Japan is no exception. Under a big governmental campaign, obese rate in Japanese elderly begins to decrease very recently. However, we cannot help to have impression that our patients who undergo hip/knee replacement surgery have been getting heavier and heavier. The purpose of this study is to examine the change of body mass in our patients and find related factors. We reviewed hospital record of patients who underwent knee or hip replacement from January 1 to December 31 in 2004 or 2012. Patient who underwent either unicompartmental or total knee arthroplasty was included, however, those who went through femoral head replacement (hemiarthroplasty) was excluded from this study population. Body mass index (BMI) was calculated from body height and weight measured within a week before surgery. Unlike in United States, BMI greater than 25 is categorized as obese, and below 18.5 is considered underweight in Japan. Additionally, gender, age at surgery, operated site (hip or knee), primary surgery or revision, blood loss in operation, surgery time, anesthesia time were evaluated as co-factors.Introduction:
Patients and methods:
We have been developed lateral flare stem and have been using it since 1989. It was custom stem at first. After being experienced, using the same software, off-the-shelf version lateral flare stem (Revelation) was developed in 1996 in the U.S. We could start using it since 2001 in our country. Lateral flare stems are designed to reproduce physiological proximal load transfer lateral side as well as medial side. It was obtained by having bigger and more accurate proximal part with lateral flare. The design is optimized by matching with 3D insertion path. Using many custom stems including different length and off-the-shelf standard stems, we have come to feel that as for this high proximal fit and load transfer design, it is not necessary to having long distal part and sometimes it is harmful to obtain good proximal load transfer in some situation such as type A (champagne flute) canal. So we have developed short version of the stem. Many makes of the hip stems have included short stems recently. Some aimed to improve easier insertion, some aimed to improve the volume of residual bone quantity. We have aimed to improve proximal fit expecting more proximal and more physiological load transfer to the femur. Our objectives are to comare standard stem and short stem from biomechanical aspect and clinical aspect.Introduction
Objectives
Massive defect of the acetabular bone is one of the severe situation in the hip arthroplasty. Installation of cup supporter or acetabular reinforcement device is one of the important method as well as big cup and bone graft etc. Preparing the device to be suitable shape is very important and installing it at the very position where the shaping was intended is also very important to obtain a stable condition for the arthroplasty. When we use navigation system, the device must be programmed in. But it is impossible to programme a device we have bended by ourselves into the system. If we can use a navigation system for such devices for those cases, we can expect better installation. We can fit the device on the patient's bone during the surgery of course; which is the ordinary procedure fot it; but it requires much time and tissue damage maybe with less accurate fitting. Two primary and three revision total hip arthroplasty cases with severe acetabular bone defect were treated with this method. First we have made chemical wood model for each case and bended the cup supporter on it. (Fig. 1) Then CAT scan of the model and the bended device on it were taken. Then the coordinate system of DICOM data set of the patient's original pelvis and the second DICOM data set i.e. the bended prosthesis were unified using MIMICS (Materialize, Belgium.) An STL format geometry data file of the bended device was extracted and merged into original DICOM dataset. Thus we could obtain a DICOM data set we call “predicted post-op DICOM.” During the surgery, a navigation system was used based on the predicted DICOM data.Introduction
Materials and Methods
In total hip arthroplasty, preoperative planning is almost indispensable. Moreover, 3-dimensional preoperative planning became popular recently. Anteversion management is one of the most important factors in preoperative planning to prevent dislocation and to obtain better function. In arthritic hip patients osteophytes are often seen on both femoral head and acetabulum. Especially on femoral head, osteophytes are often seen at posterior side and its surface creates smooth round contour that assumes new joint surface. (Fig. 1). We can imagine new femoral head center tracing that new joint surface. In the present study, the posterior osteophytes are compared in osteoarthritic patients and other patients.INTRODUCTION
OBJECTIVES
A Finite Element Analysis (FEA) is often used to examine load transfer between prosthesis and canal. Ordinary, bone elements' type is defined as elastic material. But using this element type for FEA on stem load transfer, the stems will jump out and fly away when the load is removed even friction between the stem and the canal was defined. This is remarkably different from the reality. It happens because the canal elements return to the original shape without the load. But actually, the bone is impacted by the load without returning to the original shape. Meshing the trabecular bone with a collapsible element type, it can collapse and be hardened by the stem pressure. We have been using Revelation (DJO, USA) with lateral flare for the primary cases whom we can expect high proximal load transfer. We were going to shorten its length to secure proximal load. We have been using Modulus (Lima Corporate, Italy) with conical fixation for the cases we expect mid stem load transfer and neck modification. We were going to extend its length for wider load transfer area. To examine load transfer of the designs the collapsible FEA was used. Our objectives are to examine load transfer between stems with different length and canal by collapsible FEA.Introduction
Objectives
Navigation system has been used for very accurate surgery. It can also be useful for preoperative planning. A surgeon can understand whole surgery, plan the surgery and perform the surgery three dimensionally and accurately. But the planning procedures should be installed before everything is started. When the surgery will be done in an ordinary method, the surgeon would not find particular difficulties. But in sometimes the surgeon can have unordinary situation such as massive defect that should be treated with acetabular enforcement device and bone grafted. Using postoperative DICOM data which is predicted by preoperative planning using 3D CAD software, we will be able to use the navigation system for those cases with difficulties that is not supported. To establish a method to use a navigation system using preoperative planning data that is processed by our 3D CAD software which is not supported by the navigation system itself, including device preparation using plastic models.Introduction
Objectives
To obtain a better range of motion and to reduce the risk of dislocation, neck and cup anteversion are considered very important. Especially for the reduction of the risk of dislocation, the mutual alignment between neck and cup anteversion (combined anteversion) is often discussed. A surgeon would compare the neck direction to the calf direction with the knee in 90 degrees flexion. When an excessive anteversion was observed, the neck anteversion would be reduced using modular neck system or setting the stem a little twisted inside the canal with the tradeoff of the stem stability. Another choice would be the adjustment of cup alignment. Combined anteversion is defined the summation of cup anteversion in axial plane and stem anteversion in axial plane. But in realty the impingement occurs with 3 dimensional relationships between neck and cup with very complicated geometries. In that meaning, the definition of the angles could be said ambiguous too. The bowing of the femur also makes the relationships more complicated. Upon those backgrounds, we have been performing 3D preoperative planning for total hip arthroplasty on every case. In the present study, in vivo position of the stem in each case was determined then the anteversion observed on surgical view and anteversion around femoral mechanical axis are compared using 3D CAD software. Ten recent cases from our hip arthroplasty with 3D preoperative planning were reviewed for this purpose. The bone geometries were obtained from CAT scans with very low X-ray dose using Mimics® (Materialize, Belgium). Preoperative planning for Revelation stem® (DJO, USA) was performed using Mimics® (Materialize, Belgium). Femoral mechanical axis was defined as a line between center of femoral head and the middle point of medial and lateral epicondyle of the femur. Then mechanical anteversion is assessed from posterior condylar line. On the other hand, the calf was rotated 90 degrees around epiconlylar axis of each femur, and in vivo stem position was estimated then, stem axis was aligned perpendicular to the view. The anteversion in the surgical view was assessed from that view as the angle toward the calf. (Fig. 1) Using in vivo stem alignment, the impingement angle was also assessed.Introduction
Materials and Methods
We have been using 3-dimensional CAD software for preoperative planning as a desktop tool daily. In ordinary cases, proper size stems and cups can be decided without much labor but in our population, many arthritic hip cases have dysplastic condition and they often come to see us for hip replacement after severe defects were created over the acetabulum. It is often the case that has Crowe's type III, IV hips with leg length difference. For those cases preoperative planning using 3D CAD is a very powerful tool. Although we only have 2-dimensional display with our computer during preoperative planning, 3 dimensional geometries are not so difficult to be understood, because we can turn the objects with the mouse and can observer from different directions. We can also display their sections and can peep inside of the geometries. It is quite natural desire that a surgeon wishes to see the planed geometries as a 3-dimensional materials. For some complicated cases, we had prepared plastic model and observed at the theater for better understanding. When we ask for a model service, each model costs $2,500. We also have small scale desk top rapid processing tool too, however it takes 2 days to make one side of pelvis. Observation of the geometries using 3-dimensional display can be its substitute without much cost and without taking much time. The problem of using 3D display had been the special goggle to mask either eye alternatively. In the present paper, we have used a 3D display which has micro arrays of powerful prism to deriver different image for each eye without using any goggle. After preoperative planning, 2 images were prepared for right eye and left eye giving 2-3 degree's parallax. These images were encoded into a special AVI file for 3-dimensional display. To keep fingers away from the device, several scenes were selected and 3-dimensional slide show was endlessly shown during the surgery. Cup geometries with screws had been prepared and cup position with screws direction were very useful. The edge of acetabulum and cup edge are well compared then could obtain a better cup alignment. Screws are said to be safe if they were inserted in upper posterior quadrant. However so long as the cluster cup was used, when the cup was given 30 degrees anterior rotation, 25 mm screw was still acceptable using CAT angiography.Method
Result
Dislocation after total hip arthroplasty (THA) is one of the most serious complications. We recently modified the design of Lateral Flare femoral component (RevelationV2) with six degrees lower anteversion to reproduce the normal hip condition in Japanese. In addition, we added 10-degree slope on the posterior neck to prevent dislocation especially aimed to high anteversion cases. The purpose of this study is to verify the clinical outcome after this design modification. Hospital records and database were retrospectively reviewed. We investigated 46 consecutive hips in 43 patients who underwent primary total hip arthroplasty using RevelationV2 from September 2007 to August 2009. All patients implicated preoperative planning using CAT scan with their informed consents. The mean age and BMI at surgery were 63 years old and 23.1. Preoperative diagnosis was osteoarthritis (40/46: 87%), rheumatoid arthritis (2/46: 4%) or avascular necrosis of femoral head (4/46: 9%). There were 41 hips (89.2%) of Crowe I, 3(6.5%) of Crowe II and 2(4.3%) of Crowe III. Preoperative femoral neck anteversion averaged 28 degrees, whereas postoperative combined anteversion (the sum of femoral neck anteversion and anterior cup inclination) averaged 46 degrees. During follow up, 5 complications, in details, 3 mild peroneal nerve palsy, 1 pulmonary embolism and 1 dislocation following deep infection were reported. In conclusion, although no ordinal dislocation was found in this series, longer observation will need to judge appropriateness of this new component.
One of the ironies in modern technology for arthroplasty is the stress shielding in cementless stems. The aim of the development of cementless stems had been reduction of stress shielding which cement stems are not free from. In healthy femur, trabecula start form the femoral head and reach at both medial and lateral cortex in rather narrow area around lesser trochanter. So the load from the femoral head is transferred at the level on both medial and lateral side. Cement stems should have binding to the cortical bone from collar to the tip of the stem where the cement interlays, and then the load is transferred gradually from the tip to the collar, which means mild stress shielding. When distal bonding is removed, the load could be transferred as normal femur. This should have been one of the biggest requests for cementless stem. But in realty many cementless stems have difficulty to obtain a load transfer at the level like normal femur. Since 1990, we have been mainly using lateral flare stems to obtain contact on both medial and lateral side at proximal level. In the present study, different types and length of the designs were compared by 3-Dimensional fill, 3-Dimensional fit and Finite Element Analysis. Stems from DJO: Revelation Standard, Revelation Short, and Linear stems were inserted into patients' canal geometries. Three-D fill and 3-D fit which were reported ISTA2009 and stress transfer were observed by FEA. The closest fit and fill were observed Revelation Short and Revelation Standard then Linear. The most proximal load transfer was observed Revelation Short, followed by Revelation Standard then Linear.Materials and Methods
Results
Dislocation following total hip arthroplasty is one of the most common complications, occurring in 1% to 5% of all cases. Several causes for dislocation have been suggested that
Mismatching of cup positioning and stem anteversion Impingement between cup and neck of stem prosthesis. Most often positioning of the stem is anatomically predetermined, while the orientation of the cup is much more flexible. Since July 2005, stem first method has been applied for all cases. During this method, canal preparation and stem trial was done first, and then cup orientation was determined according to the stem direction and impingement. For the bigger cups 34mm or 38mm heads were applied in this series. In the present study dislocation ratio was compared to cup first method. In the stem fist group (SF), the following procedures were done consequently.
Canal was prepared for the stem. Revelation lateral flare high proximal load transfer stem (DJO) was mainly selected. But for the case with high anteversion over 50 degrees, Modulas; conical distal load transfer stem with modular neck (Lima) was selected. According to the stem anteversion and neck length, cup position and orientation were determined. (For the cases with higher anteversion, less cup anteversion was selected, and for some cases higher cup position was selected. According to the cup size 28, 34, or 38 mm diameter neck was selected. From October 2002 to July 2008, there were 191 THA cases. There were 81 hips in Standard group and 109 hips in SF group. There were 63 females and 18 males in Standard group and 90 females and 19 males in SF group (p=0.41). Average age was 61.0(22–81) in Standard group and 60.2(29–89) in SF group (p=0.53). In Standard group, 64 were replaced for osteoarthritis, 15 for rheumatoid arthritis and two for avascular necrosis. In SF group, 86 were replaced for osteoarthritis, 17 for rheumatoid arthritis and six for avascular necrosis (p=0.53). As for Crowe’s classification, 61 type I, 18 type II and 2 type III were included in Standard group. And 88 type I, 15type II, 4 type III and 2 type IV were included in SF group (p=0.29). Average anteversion of femoral neck were 23.1(−2 to 70) degree in Standard group and 26.2(−4 to 65) degree in SF group measured with CAT scan (p=0.274). MoM bearing surfaces were used with 71 hips (87.7%) in Standard group and 100 hips (91.7%) in SF group (p=0.35). Only in SF group, big metal head were used in 24hips(22%) with 34mm and in 12hips(11%) as 38mm diameter. Average leg length difference between pre and post operation was 11.5mm(0 to 36) in Standard group and 8.0mm(−18 to 30) in SF group (p<
0.05). Average cup inclination was 43.2(25 to 84) degree in Standard group and 40.9 (22 to 66) degree in SF group (p<
0.05). Average cup anteversion was 8.2 degree (0 to 22.8) in Standard group and 7.1 degree (−12 to 30.5) in SF group (p<
0.05). Average operating time was 111.9min (67–150) in Standard group and 97.5min(60–162) in SF group (p<
0.05). Average intra operative hemorrhage was 744ml(10–2757) in Standard group and 487ml(10–1374) in SF group (p<
0.05). The dislocation rate was decreased from 3.7% (3/81 cases) in Standard group to 0.0% (0/109) in SF group. In conclusion our study suggested that Stem first method and utilization of big metal head would decrease the dislocation rate in primary cases. More bleeding from canal during accetabular reaming was expected. However less bleeding was observed in SF group.
Canal Flare Index, defined as the ratio of the intracortical width of the femur at a point 20mm proximal to the lesser trochanter and at the canal isthmus by Noble et al,; is considered to express the proximal femoral geometory, but it is usually measured by a plain A-P X-ray. Then it is thought the index is influenced by rotational position of the femur, so we made 3-D femoral model based on CAT scans and measured the canal flare index three dimensionally. Then the effect of observation from rotated direction was evaluated. CAT scans of 49 femurs (18 male, 31 female) were obtained from the pelvis to the feet. The average age was 60.4 years old ranging from 25 to 82. Forty nine femurs contained 22 osteoarthritis of hip joint, 12 trauma, 9 knee arthritis, 3 avascular necrosis of femoral head, 3 normal candetes. From those data, 3-D models of normal side were individually made for measuring the parameters. 3-D models were made using CAD software. We measured the canal flare index at which the femur posterior condyles were parallel to the plane, reproducing the situation to take A-P X-ray. After that, those 3-D models were rotated and investigated the difference of the value to study the effect of femur position. The canal flare index was between 2.8 and 6.6 with the average value at 4.65. The stovepipe (canal flare index<
3), the normal range (3~canal flare index<
4.7), the champagne flute (4.7~canal flare index), included 2%(1 femur), 61.2%(30 femurs), 36.7%(18 femurs), respectively. About the effect of rotation, we found the value of canal flare index was more sensitive to proximal femur rotation than the canal isthmus. The results of the canal flare index at the plane parallel to the posterior condyle line varied widely compared with the results at the position considering the anteversion. So it was suggested that the canal flare index at the patella front position does not represent the canal characteristics. It should be argued in 3-D space.
One of the most important characteristic of the developmental dysplastic hip (DDH) is high anteversion in femoral neck. Neck-shaft angle is also understood to be higher (i.e. coxa-valga) in DDH femora. From this understanding many DDH intended stems were designed having larger neck shaft angle. According to the result of our prior study; reported in ISTA 2005 etc.; using computer 3-D virtual surgery of high fit-and-fill lateral flare stem into high anteversion patients, it was revealed that the geometry of proximal femur itself does not have big difference from normal femora but they are only rotated blow lessertrochanter. It is very important to know what anteversion is, and where anteversion is located, to design a better stem and to decide more proper surgical procedures for DDH cases with high anteversion. In the present study, the geometry of 57 femora was assessed in detail to reveal the geometry of anteversion and its location in the DDH femora. Fifty seven CAT scan data with many causes were analyzed. Thirty-two DDH, 3 Rheumatic Arthritis (RA), 2 metastatic bone tumors, 4 avascular necrosis (AVN), 1 knee arthritis, 12 injuries, and 3 normal candidates were included. Whole femoral geometries were obtained from CAT scan DICOM data and transferred to CAD geometry data format. All the following landmarks were measured its direction by the angle from posterior condylar line. The assessed landmarks were
anteversion, lesser trochanter, linea aspera at the middle of the femur, and two more (upper 1/6, 2/6 level of aspera) linea aspera directions were assessed between ii) and iii). All the directions were measured by the angle from the medial of the femur. The direction of anteversion and lesser trochanter were well correlated, (R=0.55, Y=0.56X−35) i.e. femoral head and lesser trochanter were rotated together. The direction of lesser trochanter and aspera in upper 1/6 section had no relation even they are located very close with only several cm distance, (R=−0.03, Y=−0.02X−88) i.e. however the lesser trochanter was rotated, the upper most aspera was located almost at the same direction (−87.5+/−7.58 degree). The direction of aspera at upper 1/6 and middle femur were strongly correlated. (R=0.63, Y=0.81X-22) i.e. they stay at the same direction. The results mean that the anteversion is a twist between normal proximal femur (from femoral head and lesser trochanter) and normal distal femur. The twist was located just blow lesser trochanter within several centimeter. The anteversion has been understood as the abnormal mutual position between femoral neck and femoral shaft. In high anteversion hips the neck shaft angle was also believed to be higher, so several DDH oriented stems have higher neck shaft angle i.e. coxa-valga geometries. It has been believed that the location of the anteversion was around neck part. This study revealed that the deformity was located in the very narrow part just below lesser trochanter. It has been discussed that DDH oriented stems should have fit to different canal geometries, but understanding the biomechanics of abnormal anteversion and its treatment should be more important.
Since 1993, we have been developing preoperative planning system based on CAT scan data. In early period it was used to decide cup diameter and orientation for Total Hip Arthroplasty (THA). It was done using hemisphere object locating proper position and orientation. According to our progress, we have started using it for custom stem designing, stem selection and stem size planning too since 1995. Since 2001, we have been using it for almost all THA cases. We also have started use it for any case we have question about 3D geometries. Since 2005 we started computer planed 2 staged THA after leg elongation for high riding hips and reported at ISTA 2007 too. Now our policy became that every tiny question we have, we shall analyze and plan preoperatively. In our population, the incidence of the developmental dysplastic hips is higher. The necks often have bigger anteversion, and less acetabular coverage. So we often use screws for cup fixation. The screw direction allowed in thin shell thickness is limited and less bone coverage makes good cup fixation difficult. With highly defected cases and with revision cases the situation is more difficult. In the present study, we have developed acetabular 3D preoperative planning method with screw direction, length, and for the cases with defect, cup supporter pre-shaping with models and prediction of the allograft volume. For the less defect cases, geometries of cup with screw holes were requested to the maker and were provided for us. Screws were attached perpendicular to each screw hole. Screw geometries have marks at every 5mm to plan proper length. The cup was located as much as closer to the original acetabular edge, keeping in the limit to avoid dislocation. Small space above the cup was accepted if anterior and posterior cup edge could be supported by original bone. Then the cup was rotated until we can obtain proper screw fixation. For the cases with severe defects, we use cup supporters and allografts. Cup supporters are designed to be bent and fit to the pelvis during the surgery. But to shape it a properly; for good coverage and strong support; is very difficult and takes long through the limited window with fatty gloves. And mean while we get more bleeding. The geometries were obtained by CAT scan of the devices. Then proper size was determined as cup size. Chemiwood model was made and proper size supporter was opened and bent preoperatively using the model. It was scanned again and compared to the pelvic geometry again. Using cluster cups, no dangerous screw was found as long as normal cup orientation was decided and screws were less than 30mm. Posterior screws were often too short then rotated anterior and found to have good fixation. Pre-bending could reduce surgical time remarkably. As long as we could know, no navigation system can control the cup rotation. But acetabular preoperative planning was very useful and could reduce operative invasion. It could be done easily without using navigation system.
Axial radiographs were obtained under valgus and external rotation stress at 45° of knee flexion with and without contraction of the quadriceps muscle in order to assess the dynamics of patellar subluxation or dislocation. The radiography was performed on 82 knees in 61 patients with patellofemoral instability, and on 44 normal knees. The lateral patellofemoral angle and the congruence angle were measured and compared with the conventional Merchant views. Both parameters showed greater differences between symptomatic and normal knees on the stress radiographs obtained without quadriceps contraction. There was a major difference in the lateral patellofemoral angles between the groups, which clearly distinguished symptomatic knees from normal controls. Congruence angles on stress radiography had a significant correlation with the functional scores obtained after a period of conservative treatment and a positive correlation with the frequency of patellar subluxation. When the quadriceps contracted, two patterns of patellar shift were observed. While the patella reduced into the trochlear groove in all normal knees and about 70% of the symptomatic knees, contraction of the quadriceps caused further subluxation of the patella in the remaining symptomatic knees. All the knee joints which showed this displacement failed to respond to conservative treatment and eventually required surgical treatment. Thus, this technique of stress radiography is a simple, cost-effective and useful method of evaluating patellar instability and predicting the prognosis.
